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And the Oscar Goes to . . . “Surgery: The Movie”

We only spoke for sixty seconds, a chance meeting at the breakfast line on the last day of a conference. It was an intense minute of conversation, though, as we had met exactly one year earlier on the sun-lit streets of San Francisco. We realized then that we were both actors going through medical school, him a film actor, me a stage actor and we were eager to compare notes. When we met a few days ago, the parallel path that linked our stories became even more aligned as we both happened to have just completed our Surgery rotations. “What did you think?” he asked eagerly. “I liked it” I said. “So did I!” he responded with enthusiasm before I had barely completed my response. “It felt familiar didn’t it?” I probed, “The Operating Room is like a . . .” “A movie set!” He completed my sentence. I was actually going to say stage as I thought of the lights, the roles, the robes and rituals, but his reference point sounded interesting and I listened for more. “First, all the “techs” (nurses, students) set up the “set/OR”, then the “talent” arrives (fellow or attending) when everything is ready to “shoot” (cut). I would love to have heard more, but the program was beginning and we parted to find our seats. But my partner in crime was right, surgery is in many ways, a movie . . .

You the medical student start off as an extra. You are careful not to step into the spotlight in the center of the operative field. This is the domain of the “lead actor” (the attending surgeon). Then you have to be careful not to be in the space of the “supporting actor” or first assistant (fellow or resident). Just when you think you have successfully found your place, you bump into the “props table”, the sterile collection of instruments carefully prepared by the “props master/scrub nurse.” Sometimes the best place to watch an operation is in “the wings” behind the curtain with the “stage manager/anesthesiologist.” These are the silent controllers of the action doing things the “audience/patient” never really sees like calling light cues or maintaing adequate sedation. And yet, they are crucial to an effective “performance.” As the extra, being in the OR can feel like a thankless task. Long operations are a test of focus and patience and are also a time when many decide on their specialty . . . or at least eliminate one. The most you might do in some operations is cut the suture with a pair of scissors. But for some, and I include myself here, there are those moments when the extra does a little extra, and can make even a long operation somehow worth it. The long silence is broken with a question about the operation that leads to an insight, or the offer is made that is both terrifying at first but ultimately most satisfying, “Would you like to close?” With surgery, you move from the “table-readings” to the stage or the set and you perform with eyes on you including the residents, the nurses and the anesthesiologists. But you take the leap anyway, stumble, fall and try again. It is not for everyone, but for some . . . Like strange early morning movie shoots, surgery rotations have demanding hours that include rounds at 6am, operations, clinic, floor work, rounds again and all the patient care in between. At some point we all must ask, “How much do I want this?” or even “Do I want this?” like the aspiring performer who must also persist despite daunting odds.

*** Different colored tears***

But like most metaphors, this one reaches its limit. Surgery is not a movie. Mistakes can’t simply be edited. The sacred threshold of the body is crossed and can’t simply be cleaned up with make-up. Lives truly are at stake and are changed on a daily basis. And despite the fact that the surgery is “rehearsed” and there is a surgical plan, some moments can’t be prepared for . . . as I found out when I went on my first organ procurement while on the Transplant service. I jumped into the car, joined the fellows as we rushed off to pick up a newly available liver. We arrived at the hospital of the donor and then a few moments later they wheeled him in, a four year old boy. He looked like he was peacefully sleeping. But he wasn’t. He had been brain dead for several hours. All breaths now were external, all heartbeats created, all life illusory. It was a difficult sensation when I first saw him. I could only imagine the anguish of his parents; and yet, there were another set of parents sixty miles away feeling the swell of hope for the first time as they awaited the new liver for their sick child. They were crying different colored tears. This whole encounter felt surreal and sacred to witness. I was not expecting the fellow to say “Jonathan, come and do the final closure.” It is not unusual for medical students to help close the final skin of an operation. But this was different; this patient was not going to wake up. I felt that my suturing here was not just the sealing of a incision, but felt almost like a funeral rite. I remember thinking, “I just want this to be neat, in his honor.” Six hours later, his liver was in another little boy, and a life was changed.

Now, not every day on surgery will be this dramatic or poignant, but that day was. Like in a movie or a play, victories and failures in surgery are all too visible and that’s hard and exhilarating. Surgery is simultaneously bold, yet vulnerable, assertive yet humble, or at least should be.

And so, the operation and the performance end, the lights go out, the patient and the audience leave the room and the actor and the surgeon watch after them and silently think, “I hope what I did changed that person for the better . . .”

Third Year: From Theory to Practice . . .

Hello there! As I make my first post, I want to confess a bias. Before  medical school, I was an actor and acting teacher. So I tend to focus on the human aspects of medicine because they seem the most interesting, funny, quirky or poignant to me.

With that said, let’s get straight to the point . . what is third year really like? Here are a few early thoughts:

Third year is like finally driving after watching someone at the wheel for two years, exhilarating yet terrifying. There is this crazy tension between knowing something and knowing nothing. And so, crashing is easy. But if you take a chance, there is something about trying to  turn the corner on a patient and then seeing her improve, or at least feel cared for, that makes this wild ride worth it.

Third year is like walking into a party of strangers. You wonder what these people will be like? What is the code? What is the tone? Instant assessment and response is a skill that is constantly being tested. As the discomfort of unfamiliarity eases, now you actually meet people at this “party.” And this is where the analogy seems to fall short. Aren’t parties fun, but superficial? How deep a conversation can you have over music blaring at insane decibel levels? And yet, in medicine, the same challenge exists, except that the noise is not music, but the “noise” of the tests and technology we use to determine patient status. This technology has, of course, been life saving; but the beeps of the monitors, the clanging of the MRI, our own voices musing over the meaning of the latest lab values can drown out the one voice you need to hear, the patient.

Finding this space is hard sometimes because third year can pull you in different directions. You’re on a consult service and your resident expects you to find the patient, take a history and physical come up with a plan all within a specific time limit. It’s tempting to go through the motions to hit  that timing target. But consistently I have found that my presentations and learning always went better if I turned the “music” down, took my eye off the clock (at least for a little while) and just got to know my patient. Funny stories don’t make it to the chart. Deep fears or hopes are often untranscribed. Key health clues are often hidden under several layers of “life.” But all of these things can be captured on a “virtual chart”, created in real time, through the simple act of a real conversation.

This is third year.